Improving the science of adherence reinforcement and safe mobility in people with diabetic foot ulcers using smart offloading

The project will conduct a randomized comparative effectiveness study involving 216 ambulatory patients with active DFU, divided into three groups. The first group will receive an irremovable boot (gold-standard). The second group will use a traditional removable device with standard counseling. The third group will use a 'smart' removable cast walker with adherence reinforcement (real-time smartwatch notifications and smartphone feedback) and remote patient monitoring. All devices will be embedded with sensors to monitor adherence and activity. The study aims to examine the benefit of adherence reinforcement on wound healing (Aim 1), the association between physical activity dosage and wound healing (Aim 2), and patient-centered outcomes across the three treatment arms (Aim 3).